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A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system.
Seeing that each patient's medical record is complete, kept confidential, and safeguarded from individuals not involved with the medical care of the patient are primary responsibilities. [ 4 ] A RHIA certification is a preferred qualification for positions including health information management director, clinical documentation improvement ...
Obtaining a certificate is voluntary in some fields, but in others, certification from a government-accredited agency may be legally required to perform certain jobs or tasks. Organizations in the United States involved in setting standards for certification include the American National Standards Institute (ANSI) and the Institute for ...
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
In practice, the term medical laboratory technician may apply to persons who are trained to operate equipment and perform tests, usually under the supervision of the certified medical technologist or laboratory scientist. Depending on the state where employment is granted, the job duties between MLSs and MLTs may or may not be similar.
The AAPC, previously known by the full title of the American Academy of Professional Coders, [4] is a professional association for people working in specific areas of administration within healthcare businesses in the United States. [5]
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